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E/M Coding Changes 2021

Prepare for the significant revisions to E/M office and outpatient visits 2021.

Beginning January 1, 2021, changes to the Current Procedural Terminology (CPT®) code structure for office or outpatient evaluation and management (E/M) services will take effect. The Centers for Medicare & Medicaid Services (CMS) finalized these changes in the 2020 Medicare Physician Fee Schedule final rule. The new updates include revisions to the CPT descriptors for codes 99202-99215 and documentation standards. While private payers are not bound by CMS policy, they will likely adopt a similar coding structure.

The new documentation requirements will be based on the traditional subjective, objective, assessment, and plan format—in which physicians document what the patient was there for (subjective), what was learned from their history and exam (objective), what the physician assessed to be the problem, and the plan for resolving it.

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